Brazilian Journal of Anesthesiology 71 (2021) 90---95 LETTER TO THE EDITOR −1 −1 0.25 mg.kg and ketamine 0.25 mg.kg also have showed Cough and laryngospasm 4 being effective for such purpose. prevention during orotracheal The timing of extubation according to the child’s breath- extubation in children with ing cycle is another point of interest. The author of an SARS-CoV-2 infection educational review about extubation in children mentions that he extubates the child at the end of spontaneous inspi- Dear Editor, ration without suction or positive pressure, arguing that at this point the child’s lungs are full of O2-enriched air and that Little is mentioned about the importance of avoiding cough the first trans laryngeal movement of air that follows directs and laryngospasm during extubation in the Operating Room all secretions away from the laryngeal structures decreasing 5 (OR) in pediatric patients with suspected or confirmed SARS- the risk of laryngospasm. CoV-2 infection. Coughing is an important source of viral According to the former, from the perspective of respira- contagion among humans and must be considered a high-risk tory complications associated with extubation, it is safer for complication for the health workers. Laryngospasm, more the health personnel to perform the extubation to a deep frequent in children than in adults, compels to intervene anesthetized patient, during spontaneous ventilation at the with positive pressure on the patient’s airway increasing the end of inspiration and in lateral decubitus. Special attention described risk. Different from intubation in the OR, where must be given to the use of the medications described for the anesthesiologist has certain control on the procedure, coughing and laryngospasm prevention after the withdrawal extubation and emergence from anesthesia have a greater of the orotracheal tube. degree of uncertainty. Finally, health institutions must develop safe extubation Recently, 2020 consensus guidelines on pediatric airway protocols to patients and caregivers and perform a close management in patients with the coronavirus disease, from surveillance of adherence and results. the Society for Pediatric Anesthesia’s Pediatric Difficult Intu- bation Collaborative and the Canadian Pediatric Anesthesia Conflicts of interest 1 Society, have been published. For extubation, they recom- mend the use of closed in-line suction, deep extubation with techniques to minimize coughing and bucking (total The authors declare no conflicts of interest. IV anesthesia or dexmedetomidine), the use of protective barrier with a suction device under it to create negative References pressure and emerging, and recovering of suspected COVID- 19 patients in the OR, followed by direct transfer to the 1. Matava CT, Kovatsis PG, Lee JK, et al. Pediatric Airway Mana- inpatient ward. However, there are some issues not men- gement in COVID-19 Patients: Consensus Guidelines from the tioned in the guidelines that could help in the success of the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation extubation. Collaborative and the Canadian Pediatric Anesthesia Society. The patient position during extubation is associated with Anesth Analg. 2020;131:61---73. different outcomes. H. Jung el al. found that deep extuba- 2. Jung H, Kim HJ, Lee YC, Kim HJ. Comparison of lateral and tion in children in lateral decubitus had better SpO2 values supine positions for tracheal extubation in children: A random- in the first five minutes compared with extubation in supine ized clinical trial. Vergleich der Seiten- und Rückenlage für die decubitus (mean and standard deviation 98.3% ± 2.1% and tracheale Extubation bei Kindern: Eine randomisierte klinische Studie. Anaesthesist. 2019;68:303---8. 96.8% ± 2.5%, 95% IC 0.5---2.5, p = 0.003) and lower incidence 3. Sanikop CS, Bhat S. Efficacy of intravenous lidocaine in preven- of stridor and laryngospasm (2% and 18%, relative risk = 1.9, 2 tion of post extubation laryngospasm in children undergoing cleft 95% IC 1.4---2.7, p = 0.03). palate surgeries. Indian J Anesth. 2010;54:132---6. There is evidence about other drugs’ effectiveness in 4. Pak HJ, Lee WH, Ji SM, Choi YH. Effect of a small dose of preventing cough during extubation. In children, Sanicop propofol or ketamine to prevent coughing and laryngospasm in et al. reported a 29,9% and 18,92% reduction in laryngospasm children awakening from general anesthesia. Korean J Anesthe- −1 and cough when 1.5 mg.kg intravenous lidocaine was used siol. 2011;60:25---9. 3 3 minutes before extubation compared to placebo. Propofol Brazilian Journal of Anesthesiology 71 (2021) 90---95 5. Veyckemans F. Tracheal extubation in children: Planning, tech- d Children Hospital, Anesthesia Department, Red Cross, nique, and complications. Paediatr Anaesth. 2020;30:331---8. Manizales, Colombia a,b,c,d,∗ c ∗ Alexander Trujillo Mejía , Carlos Felipe Isaza Corresponding author. a E-mail: [email protected] (A.T. Mejía). Universidad de Caldas, Faculty of Health Sciences, 6 June 2020 Division of Pediatric Anesthesia, Manizales, Colombia b Universidad de Manizales, Faculty of Health Sciences, https://doi.org/10.1016/j.bjane.2020.09.014 Medicine Program, Manizales, Colombia 0104-0014/ © 2020 Sociedade Brasileira de Anestesiologia. c Clinica San Marcel, Anesthesia Department, Manizales, Published by Elsevier Editora Ltda. This is an open access article Colombia under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). needed this target to achieve protective mechanical venti- Sedation during mechanical lation, especially in the first 48 hours of critical illness. For ventilation of COVID-19 patients without a proposal for extubation, sedation should patients in intensive care units be light to moderate (RASS -2 or -3), associated with daily into operating rooms awakening, and this assessment was performed every two hours. Dear Editor, Midazolam and fentanyl were recommended as initial sedoanalgesia, taking into account that these drugs were Healthcare is a constitutional right in Brazil, where it is pro- efficient at lower costs and required less replacements dur- vided by public and private institutions. Its unified health ing the day, minimizing the exposure of the nursing staff to system (SUS --- Sistema Único de Saúde, in Portuguese) is uni- the virus. Continuous infusion of ketamine was as second- versal and free for anyone. The Hospital das Clínicas (HC) is line therapy for agitation and pain-control optimization. The the tertiary teaching hospital of the Faculdade de Medicina sedative recommended for the mild to moderate sedation da Universidade de São Paulo, Brazil, and is Latin Amer- phase was propofol in low doses. Dexmedetomidine could ica’s biggest hospital complex, with more than two thousand be used in patients with agitation close to extubation or as beds. Since March 2020, the Central Institute of HC provided a second option in patients in the phase of light to moderate 900 beds, being more than 300 of them dedicated to Inten- sedation for agitation control. For those patients with agita- sive Care Units (ICUs), and it became a reference on how tion or hyperactive delirium, neuroleptics such as quetiapine to handle the COVID-19 pandemic in Brazil, both for clin- or risperidone were initiated via nasoenteral tube. ical assistance for infected patients and for research and In case of impaired pulmonary compliance, severe ven- innovation purposes. tilator asynchrony, or PaO2/FiO2 ratio lower than 150, even In order to offer new venues for ICUs, 34 operating rooms with the use of optimal doses of sedative agents and opti- were used to treat one to four patients according to the mization of ventilator settings, the use of neuromuscular 1 room size, providing 76 new ICU beds. As the amount of blockers was indicated. Cisatracurium was the neuromuscu- ICU ventilators was not sufficient to serve all the beds avail- lar blocker of choice when necessary, as it is the most studied able in the hospital, anesthesia machines were used for drug in patients with acute respiratory distress syndrome. this purpose. Considering that these devices work as a cir- However, its use was not recommended for more than cuit, it raised concerns about the risk of CO2 rebreathing, 48 hours due to the high risk of weakness and diaphragmatic which could lead to narcosis, impairing patient ventilation. dysfunction of the critical patient. Continuous adminis- However, no adverse events were reported. High flow ven- tration was preferred over intermittent to minimize staff tilation was adopted to minimize this risk, preventing the exposure, although this strategy may result in increased 2 need for frequent exchanges of soda lime. On the other costs. The use of a neuromuscular transmission monitoring hand, these devices allow the use of inhaled anesthetic was indicated for patients under neuromuscular relaxation drugs such as sevoflurane, that has already proved useful drugs. Additionally, for patients under neuromuscular block- 3 in ICU. ade, we included the processed EEG monitoring to achieve In accordance with what has been reported by different adequate sedation levels. The depth of sedation was also health services around the world, in our practice, we have monitored for those patients who are not under neuro- observed that COVID-19 patients require higher doses of muscular blockade but require higher doses of sedatives to 4 sedatives than usual. The local protocol for patients under minimize the agitation. mechanical ventilation included the evaluation of the levels The adequate sedation for mechanical ventilation dur- of sedation, by the Richmond Agitation and Sedation Scale ing the COVID-19 outbreak, based on scientific evidence and (RASS), and pain, by the Behavioral Pain Scale (BPS). Deep with a rational allocation of available healthcare resources sedation (RASS -4 or -5) was recommended for patients who can contribute for better outcomes of critical patients. 91.